Sex Disparities in Left Ventricular Assist Device Implantation: Delayed Presentation and Worse Right Heart Failure.

We explored whether women undergo continuous-flow left ventricular assist device (CF-LVAD) implantation in later stages of heart failure (HF) than men, evidenced by worse preoperative right HF (RHF). We also compared two propensity models with and without preoperative RHF to assess its effect on outcomes. INTERMACS was queried from July 2008 to December 2017. Propensity model 1 matched men and women on age ≥50 years, HF etiology, body surface area, INTERMACS class, comorbidities, device strategy, temporary mechanical circulatory support, and device type. Model 2 included these variables plus LV end-diastolic diameter, right atrial pressure/pulmonary capillary wedge pressure, pulmonary artery pulsatility index, and right ventricular ejection fraction. The primary outcome was all-cause mortality. Secondary outcomes comprise RHF, rehospitalization, renal dysfunction, stroke, and device malfunction. In model 1, characteristics were comparable between 3,195 women and 3,195 men, except women more often had preoperative RHF and postoperative right VAD support and had worse 1 year and overall survival. In model 2, after propensity matching for additional risk factors for preoperative RHF, 1,119 women and 1,119 men had comparable post-LVAD implant RVAD use and survival. These findings suggest that women present more often with biventricular failure and after implantation have higher RHF and mortality rates.

Hemodynamic Assessment of Dual Obstructive Left Ventricular Assist Device Lesions.

Obstructive left ventricular assist device (LVAD) lesions are uncommon but are being increasingly recognized, particularly with the increased use of advanced imaging modalities. While heart failure symptoms and LVAD power fluctuations have a broad differential, obstructive lesions in the LVAD circuit should be considered. We present a unique case of a patient supported on HeartWare HVAD (Medtronic Inc., Dublin, Ireland) therapy, who experienced postural dizziness with objective orthostatic hypotension and occasional ventricular tachycardia. With fluctuations in LVAD flow and power, a CT scan with three-dimensional reconstruction was obtained showing outflow graft kinking. The patient was brought to the cardiac catheterization laboratory for investigation and consideration of outflow graft intervention. However, intracardiac echocardiography revealed the presence of an inflow cannula obstruction with position changes and catheter interrogation involving the outflow cannula suggestive of a gradient across the kinked area as an unlikely cause for the presentation. This case highlights the importance of a thorough interrogation for obstructive lesions in the setting of heart failure symptoms, particularly postural symptoms, in a patient on LVAD therapy, even when not identified on routine echocardiography.

Optimizing Evaluation of Patients with Low-to-Intermediate-Risk Acute Chest Pain: A Randomized Study Comparing Stress Myocardial Perfusion Tomography Incorporating Stress-Only Imaging Versus Cardiac CT.

UNLABELLED: The purpose of this study was to determine whether stress myocardial perfusion (SPECT) optimized with stress-only (SO) imaging is comparable to cardiac CT angiography (CTA) for evaluating patients with acute chest pain (ACP). METHODS: This was a prospective randomized observational study in 598 ACP patients who underwent CTA versus SPECT. The primary endpoint was length of hospital stay, and secondary endpoints were test feasibility, time to diagnosis, diagnostic accuracy, radiation exposure, and overall cost. Median follow-up was 6.5 mo, with a 3.8% cardiac event rate defined as death or an acute coronary syndrome. RESULTS: Of 2,994 patients screened, 1,703 (56.9%) were not candidates for CTA because of prior cardiac disease (41%) or imaging contraindications (16%). Time to diagnosis (8.1 ± 8.5 vs. 9.4 ± 7.4 h) and length of hospital stay (19.7 ± 27.8 vs. 23.5 ± 34.4 h) were significantly shorter with CTA than with SPECT (P = 0.002). However, time to diagnosis (7.0 ± 6.2 vs. 6.8 ± 5.9 h, P = 0.20), length of stay (15.5 ± 17.2 vs. 16.7 ± 15.3 h, P = 0.36), and hospital costs ($4,242 ± $3,871 vs. $4,364 ± 1781, P = 0.86) were comparable with CTA versus SO SPECT, respectively. SO was also superior to conventional SPECT regarding all of the above metrics and significantly reduced radiation exposure (5.5 ± 4.4 vs. 12.5 ± 2.7 mSv, P < 0.0001). CONCLUSION: Stress SPECT when optimized with SO imaging is similar to CTA in time to diagnosis, length of hospital stay, and cost, with improved prognostic accuracy and less radiation exposure. Our results emphasize the importance of SO imaging, particularly in low-intermediate-risk emergency room patients who are a population likely to have a normal test result.

Role of cardiac MRI in the assessment of nonischemic cardiomyopathies.

In this review, we will highlight the role of late gadolinium enhancement, along with other strengths available by cardiac MRI, in determining the underlying etiology of various nonischemic cardiomyopathies. Furthermore, we will also emphasize how late gadolinium enhancement may serve as a novel risk stratification tool to further impact patient care.

Incidence, management, and outcome of molar pregnancies at a tertiary care hospital in quetta, pakistan.

Molar pregnancies represent a significant burden of disease on the spectrum of gestational trophoblastic diseases. The incidence appears to be higher in women from South Asia. The purpose of our prospective study was to determine the incidence, presentation, and outcomes of all molar pregnancies at our institution. During the study period, there were a total of 16,625 patients admitted to our department; out of whom 85 patients were diagnosed with a molar pregnancy. Vaginal bleeding was the commonest symptom (94.2%); theca lutein cysts were noted in 39% of the cases. Suction, dilatation, and curettage were noted to be the preferred method in almost all cases; hysterectomy was done in 12 (14.1%) patients. Single-agent chemotherapy was employed in high-risk patients and was well tolerated. Mean followup for these patients was 5.7 months (range 1-24 months). None of these patients developed persistent trophoblastic disease, invasive mole, or choriocarcinoma during the follow-up period.